critical care final
A client with upper torso petechiae, a left femur fracture in a cast for 5 days complains to the nurse that he is SOB. The likely cause is:
Fat Embolism Syndrome.
A client is scheduled to have dialysis in 30 minutes and is due for the following medications: vitamin C, B-complex vitamin, and cimetidine (Tagamet). Which action by the nurse is best?
Hold all medications until after dialysis.
A client is taking furosemide (Lasix). To detect a common adverse effect, the nurse obtains which assessment as a priority?
Intake and output
A client asks the nurse, "What are the advantages of peritoneal dialysis over hemodialysis?" Which response by the nurse is accurate? (Select all that apply.)
"It will give you greater freedom in your scheduling." "You do not need a machine to do it." "You will have fewer dietary restrictions."
A client has an arm cast and reports that it feels really tight and the fingers are puffy. What is the nurse's best response?
"Please come to the clinic today to have your arm checked by the health care provider."
A client is prescribed heparin 6, 000 units to be given subcutaneously every 12 hours to prevent deep vein thrombosis. The pharmacy dispenses a vial containing 10, 000 units/ml. How many milliliters of heparin should the nurse give?
0.6
A client develops frequent multifocal premature ventricular beats (PVCs). Which of the following drugs will the nurse plan to administer immediately? (assume standing orders exist).
Lidocaine
A client is suspected to have rheumatoid arthritis. Which manifestations does the nurse assess this client carefully for?
Low-grade fever, fatigue, anorexia with weight loss
The physician orders 150 mg of I.M. meperidine for a client with a sports injury. The drug cartridge indicates 100 mg/ml. Which dose is correct?
1.5 ml
The nurse closely monitors a client receiving a blood transfusion because permanent damage can occur with an infusion as small as:
100 cc
A client requires 250 ml of normal saline solution IV over 2 hours. What is the infusion rate?
125 ml/hr
The client with a history of seizure disorder is having a sample for a routine serum phenytoin level drawn. The nurse who receives a telephone report of the results notes that the client's blood level of the medication is within normal range if the value reported is which of the following?
15 mcg/mL
A client has order for potassium chloride, 40 mEq in 100 ml normal saline solution over 40 minutes. A controller will be used for the infusion, along with a tubing set calibrated at 60 gtt/ml. What is the drip rate?
150 gtt/min.
What is the rate of this 3 second ECG strip?
160
A client is being treated for acute congestive heart failure with intravenously administered bumetanide (Bumex). The vital signs are as follows: blood pressure, 100/60 mm Hg; pulse, 96 beats/min; and respirations, 24 breaths/min. After the initial dose, which of the following is the priority assessment?
Monitoring blood pressure.
The nurse is obtaining the intershift report for a group of assigned clients. Which of the following assigned clients should the nurse plan to monitor closely for signs of hyperkalemia?
A client admitted 6 hours ago with a 40% burn injury.
The nurse is evaluating the status of the client who had a craniotomy 3 days ago. The nurse would suspect that the client is developing meningitis as a complication of surgery if the client exhibits:
A positive Brudzinski's sign
A client calls the telephone triage nurse to report fever, nausea, chills, and malaise. The nurse instructs the client to come immediately to the emergency room when he relates he also has which of the following?
A stiff sore neck
Based on this 3 second ECG strip, what is this rhythm called?
Normal sinus rhythm
A client has a serum creatinine level of 2.5 mg/dL, a serum potassium level of 6 mmol/L, an arterial pH of 7.32, and a urine output of 250 mL/day. Which phase of acute kidney failure is the client experiencing?
Oliguric
The nurse is caring for a client with burns covering the entire surface of both arms and the anterior trunk. Using the rule of nines, the nurse would estimate the percentage of burn surface area to be:
36%.
The client recently diagnosed with Guillain-Barre syndrome is drooling and having difficulty swallowing secretions. When the family asks why this occurs, the nurse indicates that the cause is:
Demyelination of cranial nerves responsible for swallow and gag reflex.
The ventilatory support mechanism used to increase the amount of air left in the lungs at the end of respiration is:
PEEP
Based on this 6 second strip, this ECG rhythm can be identified as:
Paced rhythm
The nurse is providing care for a dying client. The nurse would place highest priority on treating which symptoms? (Select all that apply.)
Pain Agitation Nausea Dyspnea
A client is receiving fluid replacement after 35% of the client's body was burned 12 hours ago. The nurse would evaluate the fluid resuscitation as adequate when the minimum urine output is:
45 mL/hr
A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. Using the "rule of nines," the nurse would determine that about what percentage of the client's body surface has been burned?
45%.
A client is receiving a continuous infusion of 50 units of regular insulin in 100 ml of normal saline solution at 10 ml/hour. How many units per hour is the client receiving?
5 units
Your clent is to receive 1500 mL over 24 hours. Calculate the flow rate via the infusion pump
63 mL/hr
A client is admitted to the ER after a fall from a construction site. The following neuro assessment findings were noted. Response to deep painful stimuli,verbal response is innappropriate, withdraws from painful stimuli. Calculate his Glasgow Coma Scale
9
All of the following orders are received for a client with sepsis who has a temperature of 103 degrees F (39.4 degrees C) and a blood pressure of 78/50 mm Hg. In which order should the nurse implement the orders?
???????
Diagnostic findings that will assist the diagnosis of the client with Pulmonary Embolus include:
ABG, Ventilation/Perfusion (V/Q) scan and pulmonary angiography.
A nurse is caring for a client receiving a heparin intravenous (IV) infusion. The nurse anticipates that which laboratory study will be prescribed to monitor the therapeutic effect of heparin?
Activated partial thromboplastin time. (APTT).
The cardiac rhythm on the ECG monitor indicates a rhythm of 204. The nurse would prepare to administer the following antidysrhythmic agent?
Adenosine.
The home hospice nurse is evaluating a patient who is dying of end-stage chronic obstructive pulmonary disease (COPD). The patient indicates that she is not in pain but wants something "to help my breathing." There is a list of standing orders for the hospice program. Which prescribed action by the nurse would be most helpful for this patient?
Administer morphine solution (20 mg/1mL solution) 0.25 to 0.5 mL sublingually every 2 hours as needed.
Which of the following treatments is recommended for the management of delirium in the palliative care patient?
Administration of haloperidol (Haldol)
The nurse is evaluating the respiratory outcomes for the client with Guillain-Barre syndrome. The nurse determines that which of the following is the least optimal outcome for the client?
Adventitious breath sounds.
In the ED, the patient is diagnosed with diabetic ketoacidosis (DKA). What is the nurse's first priority for managing this condition?
Airway assessment
The nurse caring for a client with burns over 40% of the body notes a hemoglobin of 9% at 12 hours after the injury. The nurse would explain that this finding is related to:
An increase in carboxyhemoglobin (COHb)
Your client is scheduled for CAT Scan with contrast. What information should be obtained prior to the procedure.
Assess for a history of allergies
A client has been diagnosed with hypertension. Propanolol (Inderal) would be contraindicated in which condition?
Asthma
Based on this 6 second strip, this ECG rhythm is called?
Asystole
Which of the following drugs may be used to correct severe bradycardia?
Atropine
A client has a small-bore nasoenteric feeding tube. The nurse assesses the following vital signs: temperature, 100.2° F (37.8° C); pulse, 112 beats/min; respiratory rate, 22 breaths/min; and blood pressure, 106/62 mm Hg. Which action by the nurse takes priority?
Auscultate lung sounds and obtain oxygen saturation
A client is 12 hours post-kidney transplantation. The nurse notes that the client has put out 2000 mL of urine in 10 hours. Which assessment does the nurse carry out first?
Blood pressure
A client is having an operation. Which assessment findings concern the nurse the most? (Select all that Apply)
Blood pressure of 90/40 mm Hg Heart rate 110 beats/min
A client is receiving Metoprolol (Lopressor) for hypertension. The nurse should ask the client about a history of which of the following:
Bronchospasms
The diagnostic study that would provide the nurse with the most relevant information related to hydration status would be:
Bun and Creatinine
Which of the following spinal cord injuries (SCI) require long term mechanical ventilation?
C 1-C 2
Which of the following drugs must be titrated to maintain the blood pressure and heart rate of a client?
Dopamine.
A client on continuous mechanical ventilation may have a cuffless ET tube as long as the tube is anchored securely
False
A burn victim in the emergency department who was trapped in a closet during a fire becomes agitated and has a rapid deteriortation in level of consciousness. The nurse would anticipate that the laboratory report will support the neurologic changes and show an increase in:
COHb.
When assessing the client with meningitis, the nurse looks for which of the following as a frequent first sign of increased intracranial pressure?
Change in mood or attention level
A 68-year old woman has chronic kidney disease and a history of type 2 diabetes. Two weeks ago, she had surgery to place a vascular graft access for hemodialysis. Which precaution will the nurse follow to ensure the function of the AV graft?
Check for a bruitt and thrill by auscultation and palpation over the site.
A client has end-stage kidney disease (ESKD). The nurse observes tall, peaked T waves on the client's cardiac monitor. Which action by the nurse is best?
Check the serum potassium level.
Which symptom requires immediate intervention during a hypoglycemic episode?
Confusion
Discontinuing a mechanical ventilator from a patient who sustained an irreversible anoxic brain injury after a severe automobile accident is a form of active euthanasia.
False
Twenty minutes after a client was admitted to the ICU for DKA management, an IV of regular insulin was started with frequent finger sticks to monitor the glucose. His potassium level is 2.5 and IV potassium supplements ordered. What assessment must be made before giving the IV potassium?
Production of at least 30 mL/hr of urine
A 40 year old client with DM, fever and vomiting experienced a moderate size pneumothorax and has an ABG value of pH 7.48, PaCO 2 30.5, Bicarb 16:
Respiratory Alkalosis.
A synchronized, coordinated preset volume of ventilatory support is:
SIMV
A client is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted?
Score on the Glasgow Coma Scale is unchanged from 3 hours ago.
A client has cirrhosis and has developed ascites and edema. Which laboratory value does the nurse correlate with this condition?
Serum albumin, 2.1 g/dL
To minimize the rise in ICP following a craniotomy, the nurse would anticipate administering the following medication:
Solu-Medrol
A client is admitted with a 3-day history of vomiting and diarrhea. The client's vital signs are blood pressure, 85/60 mm Hg; and heart rate, 105 beats/min. Which intervention by the nurse takes priority?
Start an IV of normal saline as ordered.
You have started an infusion of PRBC's and your client develops the following symptoms, fever, chills, back pain decreased urine output, dyspnea, urticaria, you suspect a severe transfusion reaction. Which of the following is correct?
Stop the infusion, give 0.9% Normal Saline, notify MD and blood bank immediately
A client with a diagnosis of left sided heart failure would have a positive assessment finding of scattered crackles. true or false
TRUE
The nurse is instructing the client who has been in the hospital with bacterial meningitis and will be going home soon. Which of the following will be of the highest priority?
Take all of the antibiotics as directed until completely gone.
A client with a brain tumor is scheduled for a CT scan. Which of these factors, if present in the client' history, would affect the nurse's preparation for the scan?
The client is allergic to seafood and iodine.
What is the primary management of Systemic Lupus Erythematous (SLE)?
The use of drugs that suppress end-organ inflammation.
A PR interval of greater than five blocks would be considered first degree heart block. true or false
True
A client with fixed and dilated pupils would indicate to the nurse that this is a sign of possible increase in ICP. true or false
True
Your client has an order for Humulin N Insulin 13 Units S.C. Q a.m. You would use the following syringe.
U-30 Insulin syringe.
Based on this 6 second ECG strip, this rhythm is called:
Ventricular Fibrillation
When should a patient with type 1 diabetes avoid exercise?
When ketones are present in the urine
A client admitted to the intensive care unit with severe dyspnea, fear, noisy respirations, sweating, pink frothy sputum and tachypnea. The nurse would recognize that the client is exhibiting manifestations of:
acute pulmonary edema.
A client has a circumferential third-degree burn on the upper left arm. The nursing assessments for this client would be modified by
assessing capillary refill in the left hand.
A client who was extubated 2 -hours ago is becoming increasingly restless. The last vital signs before extubation were pulse 88, respirations 18, blood pressure 138/78, and PaCO 2 45 mm Hg. Current vital signs include pulse 104, respirations 26, blood presure 150/88, and PaCO 2 62 mm Hg:
assist with intubation.
A client admitted to the ED exhibits raccoon's eyes and Battle's sign. The nurse interprets that these manifestations are compatible with:
basilar skull fracture
To detect an early warning of a common complication in a client with severe electrical burns, the nurse would closely monitor:
blood urea nitrogen (BUN) and creatinine.
A Lumbar Puncture is performed for assessment and therapeutic purposes. Select from below, the purpose of an LP:
collection of CSF sample for testing, measurement of CSF pressures, and administering medications
A client is receiving fluid replacement for treatment of shock and the nurse assesses a central venous pressure (CVP) of 15 cm water. The nurse anticipates the intervention of:
decreasing fluid infusion.
A client has a fenestrated tracheostomy tube in place. A tracheostomy plug will be used to allow the client to talk. The intervention by the nurse that would be essential before inserting the plug is
deflating the cuff on the tracheostomy tube.
A client taking multiple medications including Digoxin, diuretics, and an oral iron preparatoin, begins to experience ventricular dysrhythmia. As a possible cause of the problem, the nurse would consider:
hypokalemia
Which of the following symptoms would correlate with a tension pneumothorax?
hypotension, decreased CO, mediastinal shift to the left.
The nurse would keep the room temperature of a burn client at 80 0 F to prevent shivering because the act of shivering:
increases oxygen needs.
A common cause of death in the unconscious client is Pneumonia secondary to aspiration. Select from the list below, the measure(s) that will assist in preventing aspiration.
inflation of the cuff of the endotracheal tube, never administer liquids by mouth, frequent turning and positioning
Your client is admitted to the ICU with a diagnosis of Status Epilepticus. Your primary concern in prioritizing care for this client would be:
meeting the metabolic needs of the client
Which of the following medications bring about significant hemodynamic changes in clients with chronic mitral regurgitation?
nitrates and digitalis
Your client is on telemetry monitoring. When you assess his rhythm strip you note 7 large blocks between the R waves ( 42 bpm), and multiple spikes that are not followed by a QRS complex. This rhythm is indicative of :
paced rhythm with failure to capture
After surgical debridement of diseased bone, a client with acute osteomyelitis asks how long antibiotics will be administered. The nurse should respond that the antibiotic protocol will be:
parenteral antibiotics for 4 to 8 weeks, then oral agents for 4 to 8 weeks.
A client admitted to the emergency department (ED) with burns of the chest and neck exhibits a wet, shiny, weeping surface with some blistering. The nurse would document these burn injuries as:
partial thickness, second degree
You are a nurse caring for TY who has a closed-head injury. He has a GCS of 5. While giving him a bath, you note rhythmic contractions in his left hand. These contractions sequentially spread up his left arm. This seizure is called:
simple partial seizure.
The client receiving a blood transfusion complains of headache and back pain. The most appropriate initial intervention of the nurse is to:
stop the transfusion.
A client with a chest injury develops respiratory distress, distended jugular neck veins, and tracheal deviation. The nurse concludes that these manifestations are consistent with:
tension pneumothorax.
A client who sustained a head injury is intubated and receiving volume-cycle mechanical ventilation via the controlled mechanical ventilation (CMV) mode. The nurse would explain that this means:
the ventilator delivers the preset volume regardless of the client's efforts.
A pulmonary artery catheter has been inserted. The nurse recognizes that the catheter is wedged when:
the wave form becomes dampened.
Pulmonary Artery catheterization is used to evaluate fluid status and cardiac output. true or false
true
In order to assess for the effectiveness of IV mannitol for the client with cerebral edema, nurse will monitor for increase in:
urinary output
As part of the mechanically ventilated client, the nurse must exercise extreme caution and maintain aseptic tehnique to avoid cross contamination. The most critical nursing action that would avoid cross contamination, would be:
washing the hands before and after care
